A bipartisan bill introduced in Congress last week aims to improve access to critical, and in some cases, life-saving drugs. The Patients' Access to Treatment Act (PATA) would significantly limit how much consumers pay for “specialty tier” – or Tier 4 – drugs, which include biologics that treat autoimmune forms of arthritis, as well as drugs for multiple sclerosis, cancer and other serious conditions.

For drugs in Tiers 1, 2 and 3, most health plans charge fixed co-pays, such as $10, $25 and $50. But increasingly, insurance companies are moving certain drugs – mostly biologics – into a specialty tier. Instead of a co-pay, patients are responsible for coinsurance, meaning they pay a percentage of the actual cost of the drug – sometimes 25 percent or even 50 percent.  

Biologics for rheumatoid, psoriatic and juvenile arthritis can range from around $1,000 to $3,000 per month. So, in the 25 percent cost-sharing model, the patient’s responsibility could be from $250 to $750 per month. PATA, sponsored by Reps. David McKinley (R-WV) and Lois Capps (D-Calif.), would end this practice of “discriminating between medications” with a fixed co-pay for Tier 4 that is in line with Tier 3.

“The current practice is unacceptable. The percentage that a patient owes should not be so large that he or she must choose between paying for critical medications or the mortgage,” says John H. Klippel, MD, president and CEO of the Arthritis Foundation.

Last year, the Arthritis Foundation and the American College of Rheumatology co-founded the Coalition for Accessible Treatments to tackle the issue of specialty-tier pricing. The Coalition, which now has 18 members – comprised of medical and patient advocacy groups including the American Academy of Neurology, Leukemia & Lymphoma Society and National Multiple Sclerosis Society – encourages physicians and others to ask lawmakers to support PATA in the 113th Congress.

Beyond easing patients’ pocketbooks, PATA would enable physicians to practice better medicine, says American College of Rheumatology president Audrey B. Uknis, MD.

“Our goal is always to treat the patients so that the disease is well controlled. We have the ability to advance therapy – to use, in some cases, safer and more effective therapy – but are prevented from bringing a patient together with the medicine that they need,” says Dr. Uknis, a rheumatologist and professor at Temple University School of Medicine in Philadelphia. “What prevents us from doing this at times is a prohibitive cost.”